Last week, I reported on the problem of preventable harm in hospitals. It has been estimated that each year between 98,000 and 440,000 people die as a result of preventable errors in hospital. Many readers wrote in with comments about family members who were victims of flawed care. They revealed a sense of betrayal and hurt. How could hospitals — institutions we turn to for comfort when we are most vulnerable — so often increase pain and suffering?

Reducing hospital-acquired infections
About one in 25 patients contracts an infection in the hospital, resulting in 75,000 deaths each year, but hospitals have been cutting this risk by adhering to stricter protocols. The most basic is getting hospital staff members to wash their hands before touching patients. More than 160 years after Florence Nightingale cut the death rate by 95 percent in British military hospitals in Crimea largely by improving hygiene, hand washing remains inconsistent in American hospitals. It’s the most important cause of hospital-acquired infections. Without reminders and watchdogging, hospital workers forget to wash their hands most of the time before they touch patients.

My colleague Tina Rosenberg has reported on ways that hospitals are attacking the problem, including using video cameras, placing sinks in standard locations and installing sensors. Many hospitals also have prioritized hygiene around critical procedures like the insertion of catheters into major arteries or veins. Over the past four years, Ascension Health, the largest nonprofit health system in the United States, has halved its rate of bloodstream infections associated with these central line catheterizations, says Ann Hendrich, a registered nurse who heads Ascension’s quality and patient safety efforts.

Ascension Health created local patient safety teams, examined current practices, compared them with recommended practices, and brought teams together to agree on standardized “bundles” (sets of steps) — including things like how often to change a central line and how to dress it. It also instituted common standards for tracking infections, said Hendrich. Staff at Ascension Health facilities now avoid needless catheterizations and act quickly to remove them at the earliest possible moments.

One area where hospitals have struggled to cut infection rates is surgery. Part of the problem is that numerous factors contribute to infections there. Working with the Institute for Healthcare Improvement over the past four years, Orlando Health, which operates seven hospitals in the Orlando, Fla., area, has reduced deaths from incidents of patient harm by 44 percent.

Orlando Health, however, has struggled with surgical site infections. “The rate was staying flat,” explained Thomas Kelley, chief of quality and clinical transformation for the network. “So we dug deeply and created a comprehensive response. There’s no single magic bullet.”

They let surgeons know their own rates of infection and how they compared with those of peers and national benchmarks. “It had a profound impact,” said Kelley. Instead of having to impose changes, he said, surgeons came to him asking: “What should I be doing differently?”

They began limiting entrances and exits to operating rooms and stopped surgical teams from bringing in backpacks, cellphones or external scrubs; became more careful about the timely administration of antibiotics; paid more attention pre-admission to blood sugar levels, which can increase infection risks even for non-diabetic patients; and began using ultraviolet disinfection in operating rooms. The changes led in 2015 to a 21 percent reduction in surgical site infections, Kelley said.

Preventing pressure ulcers
Confined to beds, hospital patients run the risk of developing pressure ulcers, which can lead to life-threatening infections. Risks are exacerbated if patients don’t eat or drink enough, if their skin remains wet for extended periods, or if medical devices continually rest on the skin.

There’s no mystery to preventing pressure ulcers: it requires regular skin inspections and attention to hygiene, incontinence, nutrition and dehydration. Pressure ulcers can develop in as little as two hours, so the challenge is staying vigilant. When hospitals make it a priority, they see changes. The Minnesota Hospital Association reduced pressure ulcers by 40 percent with a coordinated approach. Hospitals in Pennsylvania have reported important progress, and Ascension Health, which has been focusing on this problem since 2003, reports that its rate of hospital acquired pressure ulcers is less than one-fifteenth the national average (pdf).

Preventing blood clots
Another risk associated with immobility is blood clots. Hospitals routinely screen patients — then fail to start treatment fast enough to prevent clots. Orlando Health has shifted its approach. Previously, nurses did an initial assessment, then waited for a physician to decide on treatment. Now physicians assess blood clot risks when they enter admission orders. “We created a hard stop in the medical record,” said Kelley. “They can’t go forward until that risk is assessed.” From 2011 to 2015, Orlando Health saw a 32 percent decrease in patients who developed a blood clot while in the hospital.

Early detection of sepsis
One of the most deadly infections is sepsis, which accounts for a quarter of hospital deaths. Each year 750,000 patients in the United States develop sepsis and 220,000 die. It’s the most expensive condition to treat in hospitals. Sepsis, which causes blood vessels to leak fluid, can cause organs to shut down and send the body into shock. It’s particularly dangerous for children. Doctors in busy emergency rooms can miss an early diagnosis of sepsis, which can be mistaken for a lower grade infection.

Treating sepsis early saves lives. Northwell Health, which operates a network of hospitals in New York City and Long Island, reports that its mortality rate from severe sepsis declined by more than 50 percent from 2009 to 2014. Now, when a patient comes into the hospital, staff members are on alert for signs including low blood pressure, high heart and respiratory rates, and high or low body temperature. “The combination of several of these factors causes a Code Sepsis,” explained Mark P. Jarrett, Northwell Health’s chief quality officer. The hospital will start the patient on fluids, rush a blood test, and perhaps start antibiotics. “Time is really of the essence. If it turns out they don’t have septic shock, you’re not going to worsen things by being more aggressive.”

In recent years, the Washington State Hospital Association has also attacked sepsis. Carol Wagner, the senior vice president for patient safety, reports that between 2011 and 2014, state hospitals saw a 36 percent reduction in severe sepsis and septic shock compared with the 2010 rate. The hospital association estimates that this reduction has saved 3,600 lives.

The medical profession distinguishes falls based on the cause: accidents (because of an unsafe environment), anticipated physiological falls (associated with a known health condition) and unanticipated physiological falls (from sudden events, like a heart attack or stroke). Many hospitals focus on the environment, eliminating slippery or trip-prone surfaces, placing grab bars or walking aids within reach, and keeping beds and chairs at the right height. But most can do more to prevent anticipated falls. “Our approach has been to identify risk factors for patients, mitigate if treatable, or compensate,” said Patricia Quigley, associate director of the patient safety center of inquiry for the V.A.’s Sunshine Healthcare Network.

Many elderly people have poor sensation in their feet. Better management of diabetes, and exercise, can improve this. Good rubber-soled shoes with closed heels and toes are important, says Quigley. (Tennis shoes are ideal.) Elderly patients often experience a dizzying drop in blood pressure when they stand up. Cutting back on diuretics, giving fluids, or modifying other medications, can help. For stroke patients, it’s important to get out of bed from the “safe exit side.” Gerontologists know these things; but, as with hand washing, the challenge is getting patients, hospital staff and families to remember them. “For us, the primary outcome has been reducing injury from falls,” says Quigley.

“Death and Transfiguration,” a 25-minute tone poem by Richard Strauss, is the type of entertainment I’ve tried to avoid since becoming a hospice nurse. I worry it will make me feel the job too deeply in my time off. But this performance was by the Pittsburgh Youth Symphony, in which my son plays first violin, so we went.

The conductor, Lawrence Loh, began the concert by excerpting a repeated theme in the Strauss piece that he said represented a dying man’s “irregular heartbeat.” He went on to describe the piece itself, how it is broken into four parts that roughly correspond to a series of steps toward death: A man understands he is dying, he physically experiences the battle between life and death, he sees his life pass before him and, finally, at the moment of death, achieves transfiguration.

Eloquent though Mr. Loh was, at some point I stopped listening, because hearing those evocative measures transported me back to my own repeated theme, from my work as a hospice nurse: a memory of a dying patient, an elderly man in his home, experiencing the battle between life and death not as a move toward transfiguration, toward a more beautiful state of being, but as uncontrollable pain and spitting up of blood.

It’s an odd thing, to take care of someone who is chained to a bed, guarded 24/7 by bored corrections officers idling away time with TV and card games, who cannot receive visitors or even phone calls. But it happens when prison inmates are sick enough that they need care that only a hospital can provide.

As a nurse caring for such patients, the first rule I learned — or figured out, because no one said it aloud — was not to ask what the prisoner had done to land him (they were all men) in jail. Better not to know that he is a serial murderer, a vicious rapist. It was easier for me to think of the prisoners as people, just like the rest of our patients, rather than to condemn, because condemnation and compassion are tough impulses to reconcile.

I cared for one prisoner over several weeks, and I got to know him in a vague “don’t ask, don’t tell” way. He had an above-the-knee amputation and could walk only with an artificial lower limb, which we kept propped against the wall whenever he lay down. His other leg, the whole one, was handcuffed to the bed. He was very sick from cancer and chemotherapy. It seemed absurd.

“He’s a nice guy,” I told a corrections officer one day after the prisoner and I had talked. Read more…

Mary White makes house calls. She’s a senior community health worker in Philadelphia in the IMPaCT program at the Penn Center for Community Health Workers. She has 25 of the University of Pennsylvania Health System’s toughest patients. It’s her job to help them set health goals and, step by step, carry them out.

One of her patients is Grover Wilson, an engaging man of 56 who weighs 515 pounds. Wilson had long been athletic and sociable, the organizer of a long-running community volleyball game. But depression and an injury led him to gain weight. Now he lives in a tiny basement apartment packed floor to ceiling with boxes of his possessions, and is trapped and isolated by his weight. Read more…

In 1846 Arabella Wharton Griffith, a 22-year-old from rural New Jersey, moved to New York City to take a position as governess. Armed with a vibrant personality and keen intellect, she soon found herself in a circle of well-connected, literary-minded socialites, artists and prominent politicians, including the inveterate diarist George Templeton Strong. She was, he wrote, “certainly the most brilliant, cultivated, easy graceful, effective talker of womankind, and has read, thought, and observed much and well.”

Shortly before the Civil War, Arabella met Francis Channing Barlow, who had been raised by his mother in the intellectual hothouses of Brook Farm and Concord, Mass. After graduating from Harvard, Barlow moved to New York where he commenced a legal career. Arabella was a decade older than Frank, as his friends called him, but the age difference didn’t seem to matter: The couple married on April 20th, 1861, the same day that, following President Abraham Lincoln’s call for volunteers, Barlow enlisted in the Union Army.

The next year Arabella followed him into service, volunteering as a nurse in the United States Sanitary Commission, the forerunner of the Red Cross. On Sept. 16, 1862, she arrived on the battlefield of Antietam, just in time to see her husband carried off the field with a piece of case shot in his groin. Read more…

A lot of nurses hate the Showtime series “Nurse Jackie,” which will wrap up its sixth season on Sunday evening. Actually, to be precise, they hate the show’s lead character, the emergency department nurse Jackie Peyton. There’s much to dislike: She is an adulterer, a liar, an unreliable mother and, most significantly, addicted to prescription painkillers. (That’s hardly giving anything away, but be warned: spoilers ahead.)

Many nurses will tell you that Jackie’s addiction makes the entire profession look bad. Lives are at stake in hospitals, and health care requires constant multitasking and focused attention. A nurse — or doctor — tanked up on OxyContin is likely not only to do a poor job, but also to place patients in jeopardy.

Still, I see the show differently: Despite the fact that Jackie is a seriously flawed human being, the show itself is a standout portrayal of nursing, when TV almost always gets nursing wrong. Read more…

San Francisco General is largely a hospital for the poor. It’s the city’s safety net hospital, known for providing free care for all who can’t afford it, and for its display — while you wait and wait — of the parade of humanity in all its glory.

It might be surprising, then, that according to data compiled by the state (pdf) it is probably the safest place in California to have a baby. Not the most luxurious, certainly — the labor and delivery ward in the famously dilapidated complex of buildings is strictly industrial. Since the hospital doesn’t accept money from formula companies — the usual providers of baby swag — mothers go home with blankets and baby caps made by volunteers from the Baby Love Ministry at Grace Episcopal Church in Napa, and diaper bags filled with breast pads the hospital purchased using money from a grant.

Factors like a doctor’s schedule often influence whether a C-section is performed.

While San Francisco General’s maternity ward does not provide luxury, it does something else very well: evidence-based medicine.

The evidence says doctors should do far fewer cesarean sections — the American College of Obstetricians and Gynecologists sets a target rate of 15.5 percent for first-birth low-risk C-sections.Read more…

As a nurse, I often worry that patients’ comprehension of doctors and nurses is equally limited — except what the patient hears from us is: “Blah blah blah Heart Attack blah blah blah Cancer.”

I first witnessed one of these lost-in-translation moments as a nursing student. My patient, a single woman, a flight attendant in her early 30s, had developed chest pain and severe shortness of breath during the final leg of a flight. She thought she was having a heart attack, but it turned out to be a pulmonary embolism: a blood clot in the lungs. Treatment required several days in the hospital. Already far from home and alone, she was very worried that a clotting problem would mean she could no longer fly.

Photo

Credit Johnny Selman

When the medical team came to her room, they discussed her situation in detail: the problem itself, the necessary course of anti-coagulation treatment and the required blood tests that went with it. To me, just at the start of my nursing education, the explanations were clear and easy to follow, and I felt hopeful they would give my patient some comfort.

After the rounding team left, though, she turned a stricken face to me and deadpanned, “Well, that was clear as mud, wasn’t it?” Read more…

My patient was shaking uncontrollably. People say such shaking feels unbelievably bad, but rigoring, as the medical profession calls it, is treatable with the narcotic Demerol. I hurried to the computer to order some from the pharmacy, thinking “rigors = Demerol.”

But the computer listed drugs by their generic names only, and Demerol is a brand name. In the heat of the moment my mind went blank; I couldn’t get the medicine my patient needed. An embarrassed call to the pharmacy yielded the correct name — meperidine — and my patient got relief. Still, it was a reminder of how needlessly dangerous our drug-labeling system is.

In the context of what’s at stake in health care, the practice of giving drugs two names, a brand name and a generic name, makes no sense. Is there any other industry in which thousands of component parts are insistently given two dissimilar names, even though people can suffer, be hurt, possibly even die, if a mistake in names is made? Every drug with two names — and that means practically every drug in use — is a medication error waiting to happen. Read more…

We nurses all have stories — if we’re lucky, it’s just one — about the time we failed a patient. It’s usually a problem of being too busy: too many cases, too many procedures to keep track of until one critical step, just one, slips through our frenetic fingers and someone gets hurt.

I saw it happen the first time while in nursing school. A patient needed an escalating dose of pain medicine. Her pain eased, but her breathing slowed and her oxygen level dropped. I told her nurse that the patient might need narcan, a reversing agent for opioids.

“Narcan?” The nurse didn’t have time for that. Caring for eight patients on a busy medical-surgery floor meant that getting through the day’s tasks took up all her time. Half an hour later, though, the patient needed an emergency team to revive her. I held her hand while an anesthesiologist stuck a tube down her throat. She ended up in intensive care.

It would be easy to blame the nurse. How could she be too busy? But she was a good nurse, smart and committed. She simply had too much to do, too many acute needs to address. And then one, just one, got out of control. Read more…